Failure to use suitably medically qualified clinicians for home mental health assessments has been blamed for the suicide of a man in Essex by a coroner.
An Essex coroner has now written to Essex Partnership University Trust whose care Jan Goodliffe was under up to his death on June 15, 2021, “there is a risk that future deaths will occur unless action is taken”.
Mr Goodliffe, who died at an address where he worked in Rochford, had been struggling with mental health problems for a long length of time and had even spent periods in hospital as an inpatient.
But despite being well diagnosed with bipolar disorder he was visited by care workers rather than medically qualified clinicians when his symptoms became significantly serious enough to warrant a home assessment.
And despite repeatedly telling them his wishes that he wanted to take his own life, he was deemed not at risk of suicide even though Mr Goodliffe’s wife had told them of his attempt to take his own life a short while earlier, the report set out.
His mental health had already been seriously undermined after he was forced to go without medication during May 2021 due to mistakes around his organising his repeat prescription.
The care workers who attended to see Mr Goodliffe were told of this apparent decline – he had at that appointment restarted this medication – but were seemingly satisfied.
Michelle Brown, the area coroner for Essex, has said in a report to prevent future deaths: “During the course of the inquest, it revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken.”
She added: “As they were unqualified medical practitioners, there were missed opportunities to seek qualified medical advice around the interactions of the medication and whether as a result of this contributed to his death.
“I am concerned that suitably medically qualified clinicians are not being used in the home assessments and decisions are being made around issues that require medical expertise.”
Paul Scott, Chief Executive Officer of Essex Partnership University NHS Foundation Trust (EPUT) said: “Our thoughts are with the family and loved ones of Jan Goodliffe.
“We are currently working with the area coroner for Essex to find ways to improve our services in the future.
“We are committed to learning from complaints, incidents, staff and patient feedback and the outcomes of inquiries.
“Across EPUT, we will continue to view every safety-related incident as an opportunity to learn and make sure lessons are shared across the trust and with partners.
“We want leadership in patient safety to take place at all levels – from board to ward, to ensure patient safety is everyone’s responsibility.”